Abstract
Implications for Education, Practice, Research, or Policy
Nearly one-half of nurses in this survey left their first positions within their first of practice citing professional issues and lack of open communication as a reason. When nurses perceive that patient safety is compromised, their intention to leave increases. Open communication, staffing and work pace, and organizational learning were identified by new nurses as important in determining turnover intention.
According to Nursing Solutions, Incorporated (NSI; 2024), in 2023, 23.8% of all newly hired RNs left their first job within a year, which accounted for 34% of all RN separations. Job persistence among nurses is essential for the optimal, safe functioning of the health-care system. Turnover leaves fewer nurses available for patient care and, more importantly, causes a drain of expertise and experience from the care team. Frequent nurse turnover can impact patient safety due to changes in skill mix, use of temporary staff, and challenges to performance management and supervision (Silvestre et al., 2017). Furthermore, turnover is expensive. NSI (2024) estimates that in 2023 the average cost of turnover for a bedside RN increased 7.5% to $56,300. Each percent change in RN turnover will cost/save the average hospital an additional $262,500/year. Decreasing new nurse turnover is good for both the welfare of patients and the hospital's bottom line. However, to determine the best ways to encourage new nurses to stay in their positions, we must first understand why they are leaving.
Nursing in Crisis
The crisis in nursing had been simmering for more than two decades. Researchers such as Aiken et al. (2002) and Needleman et al. (2002) demonstrated that nurse staffing had a direct effect on the quality of patient care and patient mortality. All this attention on nursing and safety occurred against a backdrop of warnings about an impending nursing shortage. The COVID-19 pandemic brought the simmering crisis to a full boil by altering existing health-care practices, causing an explosion in the need for hospital beds for the acutely ill, and often leading to staffing and supply shortages. In an integrative review of the literature, Falatah (2021) found that prior to the pandemic, the nursing profession had one of the highest turnover intention rates when compared to other health professions. During the COVID-19 pandemic, nurses’ mean rates of intention to leave increased. Even though the acute effects of the COVID-19 crisis have abated, nurse turnover remains a significant problem.
The issue of turnover is especially problematic for new graduate nurses. The transition from student to registered nurse is challenging and stressful (Casey et al., 2004; Fink et al., 2008; Meyer et al., 2017; Meyer & Shatto, 2018; Shatto et al., 2016). There are many factors that make the transition to practice stressful for new nursing graduates. Although new graduates tend to enter the practice environment with high expectations and enthusiasm, they are soon confronted with the reality of patients requiring high levels of care. They report feeling stressed due to overwhelming professional responsibilities, concern for patient safety and feelings of being unprepared for the care complexity and workload and for co-workers who are frequently unwelcoming and critical (Çamveren et al., 2020; Gardiner & Sheen, 2016; Meyer & Shatto, 2018).
Purpose
New graduate nurses represent the future of health care. Increasing their job persistence is crucial, but to do that we must first understand why they leave. The purpose of this study was to explore factors that are associated with turnover intention in the first job of new nursing graduates. This study examined the following questions:
How do personal and professional factors (e.g., demographics, grit, and professional satisfaction) influence new nurses’ intention to leave their first job? How do perceptions of their institution's patient safety culture affect new nurses’ intention to leave their first job?
Methods
Sample
Inclusion criteria for the sample included RNs who were newly licensed in 2021. We contacted the State Boards of Nursing from all 50 states and the District of Columbia; despite repeated attempts, only 31 of the 51 Boards of Nursing replied. Obtaining a sampling frame was challenging. To create the sample, lists that contained names, mailing or email addresses, and date of initial registration were needed. Privacy laws prevented some states from sharing any information and only four states were able to provide email addresses. Other states provided lists that contained inadequate information; some did not provide nurses’ names; others did not provide initial date of registration or any contact information. Costs for the lists were another barrier as lists ranged from free to $1500. Funding for this study limited us to procuring lists from those states whose fees were under $200. Eight states were included in our final sample. Due to cost constraints of postage, participants were chosen randomly from these eight states for mailed surveys. All newly licensed nurses from the four states that provided email addresses were contacted.
A total of 6997 surveys were emailed or sent via the United States Postal Service. Out of this number, 373 surveys were returned (a 5% response rate); 258 contained usable data (surveys were eliminated if respondents did not meet inclusion criteria). The analyses in this study are based on the responses of the 258 nurses who were newly licensed in 2021.
Instruments
Surveys on Patient Safety Culture
The Surveys on Patient Safety Culture (SOPS) Hospital Survey (Version 2.0; Sorra et al., 2021) was used to measure respondents’ views on the culture of their hospital community (e.g., management, unit staff, practices) with respect to how well it valued and involved cooperation that prevents and responds effectively to threats to patient safety. The present study used all 10 subscales of the survey (Sorra et al., 2021). This work also used two single-item measures from the survey that addressed the number of patient safety events reported in the past year and a global rating of patient safety of a respondent's unit or work area (Sorra et al., 2021). Respondents scored the Communication About Error, Communication Openness, and Reporting Patient Safety Events subscales using a 5-point rating scale that ranges from never (1) to always (5). The remaining multi-item scales were rated on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). Participants also had the option of responding does not apply or don’t know on each of the items of the 10 subscales (Sorra et al., 2021). The global rating of patient safety was scored using a 5-point rating scale ranging from poor (1) to excellent (5) while the number of events reported in the past year is grouped for respondents into five options ranging from None to 11 or More (Sorra et al., 2021). Composite scores of the multi-item subscales were generated by averaging across their respective items, with higher scores reflecting higher levels of a particular domain of a culture of patient safety. Items were reversed scored before generating composite subscale scores in keeping with the SOPS Hospital Survey 2.0 instructions. Cronbach's α among the multi-item subscale scores ranged from .636 to .852 in the current study.
Short Grit Scale
Duckworth et al. (2007) describe grit as “perseverance and passion for long-term goals” (p. 1087). They further characterize grit as the individual's capacity to overcome challenges, and maintain effort and interest despite failure (Duckworth et al., 2007) The Short Grit Scale (Grit-S; Duckworth & Quinn, 2009) was employed to capture the degree to which respondents self-reported their pattern of effort and consistent interest in long-term goals, regardless of inconsistent outcomes (Duckworth et al., 2007). Respondents rate all eight items on a 5-point scale ranging from not like me at all (1) to very much like me (5) (Duckworth & Quinn, 2009). Grit-S subscale item responses are averaged to yield a composite grit score with higher scores reflecting higher levels of consistent interest and persevering effort (Duckworth & Quinn, 2009). Scores on the Grit-S scale have a history of adequate validity and reliability (e.g., Cronbach's α = .82; Duckworth & Quinn, 2009, p. 171). In the current study, the Grit-S scores exhibited a Cronbach's α of .751.
Education Professional Satisfaction Scale
The Educational Professional Satisfaction Scale (EPSS; Meyer et al., 2017) is a six-item measure of how satisfied an individual is with their occupational choice of nursing. Respondents rate each item on a 4-point rating scale ranging from strongly disagree (1) to strongly agree (4). For example, on the first EPSS item, respondents are asked to rate the degree to which they agree that they are satisfied with their nursing education. In the current study, the six items were averaged across participants to yield scores that are interpretively consistent with the 4-point rating scale. Higher scores suggest higher levels of occupational satisfaction with nursing while lower scores imply lower levels of satisfaction. Prior studies have indicated that the EPSS scores exhibit satisfactory reliability (e.g., Cronbach α = .77; Meyer & Shatto, 2018, p. 277). In the present work, EPSS scores exhibited a Cronbach's α of .838.
Intent to Quit Scale
The Intent to Quit Scale (Lichtenstein et al., 2004) is a three-item measure of the degree to which a respondent is motivated to consider leaving their current position. Respondents scored each item on a 7-point scale, which ranged from strongly disagree (1) to strongly agree (7). The ratings were averaged across the items to form composite scores. Respondents with higher scores reflect higher levels of motivation to leave their current position. The Intent to Quit scale is supported by a history of consistent reliability and validity with a Cronbach's alpha of .81 (e.g., Lichtenstein et al., 2004). In the current study, the Intent to Quit Scale scores exhibited a Cronbach's α of .929.
Ethical Considerations
Institutional Review Board approval from Saint Louis University (#32687) was obtained. This was a confidential electronic survey. The first page of the survey described the purpose of the study and assured participants that their answers would be kept confidential. They were also told that they could choose not to complete any questions and could stop the survey at any time. Participants gave consent by clicking to enter the survey. Once they entered the survey, data collection began. To enter the gift card drawing, participants were directed to a separate survey to provide contact information.
Data Collection
Each nurse in the sample received a letter explaining the study via either postal mail or email. The letter provided a QR code or email link to access the confidential electronic Qualtrics survey. Participants who completed the survey had the option of being entered into a drawing for $50 gift cards.
Data Analysis
To help address the first research question, the Mann-Whitney U test was used to evaluate any potential associations between Intent to Quit scores and year graduated (2020 or 2021), nursing degree (Bachelor's or Associate), workplace (hospital or non-hospital), and whether the respondent was still working in their first job as an RN. Spearman's ρ was employed to evaluate for potential associations between Intent to Quit scores and age, EPSS scores, and Grit-S scores, also in keeping with the first question. To address the second research question, Spearman's ρ was used to evaluate the potential bivariate associations between Intent to Quit scores and the domains of hospital patient safety culture assessed using the SOPS Hospital Survey 2.0. Since it is likely that the personal characteristics variables and the subscales of the SOPS Hospital Survey 2.0 share overlapping variability in their relationship with Intent to Quit scores, linear regression was used to evaluate the unique contributions of each predictor given the set of study variables. Intent to Quit scores were regressed onto all available study predictors simultaneously. Diagnostics (e.g., monotonicity) were inspected for conditions inconsistent with valid inference prior to interpreting any of the statistical models implemented in this study. Missing data was low (<11%) across all variables and was subsequently ignored.
All associations were evaluated under an α of .005 and by using common guidelines for interpreting effect size magnitudes (e.g., Schober et al., 2018). Bayes factor bound (BFB) was also included where appropriate to help approximate the highest likely odds for the alternative hypothesis relative to the null (Benjamin & Berger, 2019). All statistical analyses were conducted using JASP (JASP, 2023).
Results
The mean age of the sample was 29.813 (sd = 7.087). The sample was 88.372% (n = 228) female, 44.574% (n = 115) had an Associate's Degree in nursing and 54.264% (n = 140) had a Bachelor's Degree in nursing, and 74.806% (n = 109) worked in a hospital setting.
Evaluation of Spearman correlations between Intent to Quit scores and measures of professional satisfaction, grit, and patient safety perceptions revealed multiple significant correlations with magnitudes ranging from .084 to -.534 (see Table 1).
Differences in Intent to Quit Scores by Professional Characteristics.
As displayed in Table 2, EPSS, Staffing and Work Pace, and Organizational Learning scores exhibited significant levels of covariance with Intent to Quit scores. The remaining factors in the SOPS survey also displayed statistically significant associations, except for Number of Events Recorded (rsp = .084, p = .203). While Grit-S scores exhibited suggestive significance with Intent to Quit scores, the correlation coefficient was low (rsp = -.132, p = .044) and BFB indicated that there may be a 27.196% chance that the correlation does not differ meaningfully from zero.
Associations Between Personal Factors and Perceptions of Patient Safety with Turnover Intention Levels.
Note. rsp = Spearman's correlation coefficient; t = one-sample t-test; df = degrees of freedom; M = mean; SD = standard deviation; Mdn = median; IQR = inter-quartile range; BFB = Bayes factor bound; α = Cronbach's alpha.
Linear regression was used to help elucidate the unique contributions of the major study variables on participants’ views on leaving their current position. As displayed in Table 3, only scores on Staffing and Work Pace and EPSS scores exhibited significant covariance with Intent to Quit scores, given the set of study predictors. After controlling all other predictors in the model, every one-unit increase in Staffing and Work Pace scores yielded an approximate decrease of .651 in Intent to Quit scores. Likewise, every one-unit increase in EPSS scores yielded an approximate decrease in Intent to Quit scores of 1.014. Of note, whether the respondent was still serving in their first job as an RN, and Organization Learning levels, were suggestive of statistical significance.
Regression of Demographic and Major Study Variables Onto Intent to Quit.
Note. NER = Number of events reported; PSR = Patient safety rating; b = unstandardized slope coefficient; SE = standard error; bz = standardized slope coefficient; CI = Confidence interval; LB = lower bound while UB = upper bound.
First Job Turnover and Differences in Personal and Professional Factors
Among respondents who indicated they were not currently working their first job as an RN (n = 118), approximately 66.102% (n = 78) were in their second full-time position and 19.492% (n = 23) were in their third full-time job. Among those not currently working their first job as an RN, 81.00% (n = 96) had left a previous position over professional issues (e.g., salary, schedule) while 12.70% (n = 15) left over family issues (e.g., relocation). Evaluation of the major study variables between participants who were currently working their first RN job and those with a history of multiple RN positions revealed few differences. Only scores on the open communication subscale of the SOPS tool produced a mean difference between the two groups suggestive of significance (p = .040).
Discussion
This study surveyed new graduate nurses who were licensed in 2021. Nearly one-half had left their first positions within their first year of practice. Of those who left, almost 20% were in their third position. This finding is similar to the 2023 NSI Nursing Solutions staffing report (2024) which found that more than one quarter of newly hired RNs left their first positions within a year of employment. Of those RNs in this study who had left their first positions, 81% left due to professional issues and were more likely to cite a lack of open communication. Open communication is defined in the SOPS Hospital Survey as the ability of “staff to speak up if they see something unsafe and feel comfortable asking questions” (Sorra et al., 2021, p. 3). The increased concern with open communication among new nurses was not identified in a pre-pandemic study by Forbes III et al. (2020).
Another professional issue nurses in this survey identified as important was patient safety. Every composite measure in the SOPS Hospital Survey exhibited statistically significant negative correlation with turnover intention, indicating that lower perceptions of patient safety among nurses are associated with heightened intentions to leave their positions. The regression analysis indicated that Staffing and Work Pace and Organizational Learning were particularly important in determining turnover intention. SOPS defined staffing and work pace as “having enough staff to handle the workload, staff work appropriate hours and do not feel rushed and there is an appropriate reliance on temporary, float or prn staff” (Sorra et al., 2021, p. 4). Organizational learning is defined by SOPS as “the extent to which work processes are regularly reviewed, changes are made to keep mistakes from happening again and changes are evaluated” (Sorra et al., 2021, p. 3). These graduates began work in the chaotic environment associated with the COVID-19 pandemic, in which there were insufficient staff, and they were unable to deliver the type of care they had been taught to give and desired to do (Lasater et al., 2021). Sheppard et al. (2022) found that, during the pandemic, nurses who had concerns about patient safety displayed 2.9 times the intent to leave than those nurses who did not feel concerns about patient safety. In a study published in 2024 (Berthelsen & Hansen) nurses who questioned their ability to deliver safe and professional care reported decreased job satisfaction and increased intentions to their leave their positions.
Duckworth et al. (2007) describe grit as “perseverance and passion for long-term goals” (p. 1087). They further characterize grit as the individual's capacity to overcome challenges, and maintain effort and interest despite failure (Duckworth et al., 2007). Long-term motivation is more evident in gritty individuals, and helps them deal with negative life events (Blalock et al., 2015; White et al., 2017). The gritty individual is more likely to ‘stick’ when the going gets rough. While grit was correlated with turnover intention in our sample, surprisingly, there is no difference in grit among those who left and those who stayed in their first jobs. In Duckworth and Quinn (2009) study of 300 individuals aged 25-34, the mean grit level was 3.2 while our sample displayed a mean grit of 3.73. It could be speculated that these new graduates may be ‘grittier’ from having completed their nursing education during the time of COVID-19 and all the changes that ensued.
The EPSS scale measures satisfaction with one's education and profession. Results from this study indicated lower overall satisfaction levels in every category than were present in a sample of new graduates in 2013 and 2014 (Meyer et al., 2017). The EPSS score was the strongest predictor of turnover intention in this study. Professional satisfaction has been widely identified as one factor that increases job persistence in nurses (Hiler et al., 2018; Labrague & de Los Santos, 2021; Slåtten et al., 2022). In a Norwegian study, Slåtten et al. (2022) found that levels of job satisfaction explained almost 60% of turnover intention in their sample.
Implications for Nurse Leaders
Solving the new nurse turnover problem has been an issue since Kramer (1975) first described the reality shock phenomenon. Unfortunately, there is no “one-size-fits-all” solution to solving new nurse turnover; each environment is unique. A variety of strategies have been attempted including new nurse residencies, mentorship programs, and career ladders (Rowen et al., 2024). A variety of educational strategies have also been attempted to better prepare graduates both in the clinical and educational settings, such as simulations, role playing, and increased precepted experiences (Shatto et al., 2022).
What must be remembered when implementing any of these strategies is that “culture trumps strategy every time” (Krishnan, 2023, p. 1). Gaining feedback from nurses who have either resigned or expressed an intention to leave is paramount. Nurse managers themselves must ask the questions “Why are you leaving?” and “What could we have done to keep you?” Gaining insight into the particulars of the unit culture that may be influencing these nurses to leave is essential to the development of a creative strategy that makes them want to stay. In our study, open communication, staffing and work pace, and organizational learning were identified by nurses as particularly important factors in turnover intention.
It is also important to focus on those nurses who stay. What in the culture do they value? The goal is to create a gritty culture that knows and lives its core values, is respectful, and features continuous communication (Meyer & Shatto, 2022).
Limitations of Study
The primary limitation of any study that uses convenience sampling is the potential for selection bias. Individuals who choose to participate are often those with strong opinions or greater availability to answer surveys. These participants’ views may not accurately reflect the broader population of newly graduated nurses. Other limitations in this research were difficulty obtaining contact information for newly licensed nurses from states’ Boards of Nursing, and the 5% response rate. Postal mail and email had similar return rates. In future studies, focusing on one state or geographic area may increase response rates, while further limiting generalizability.
Conclusion
Understanding the experiences of new graduate nurses is crucial as nurse administrators and educators look toward the future. To design effective solutions to increase job persistence in new nurses we must first understand the culture in which they work and why they may want to leave it. Findings from this study indicate that perceptions of poor patient safety and a lack of professional satisfaction were strongly correlated with new nurses’ turnover. Nurses at all levels in the organization must work together to create cultures in which new nurses feel safe, supported, able to give quality patient care, and able to communicate openly.
Footnotes
Acknowledgements
The authors would like to thank the Trudy Busch Valentine School of Nursing, Saint Louis University, for their support.
Author Contributions
The authors would like to thank the Trudy Busch Valentine School of Nursing, Saint Louis University, for their support.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Saint Louis University School of Nursing, (grant number Internal Funding).
Author Biographies